<div class="reg" data-page="5">
  <div class="container">
    <!-- focus -->
    <div class="focus">
      <div class="focus-title"><span class="text-primary">最专业</span> 老虎机平台</div>
      <div class="focus-sub-title"><span class="text-primary">7×24</span> 在线服务</div>
    </div>
    <!-- /focus -->
    <form>
      <div class="row">
        <div class="col-xs-12 col-md-6">
          <div class="reg-panel">
            <h3>账户信息</h3>
            <div class="form-group has-feedback">
              <input type="text" class="form-control" placeholder="帐号" autocomplete="off">
              <span class="text-primary glyphicon glyphicon-star form-control-feedback"></span>
            </div>
            <div class="form-group has-feedback">
              <input type="password" class="form-control" placeholder="登录密码" autocomplete="off">
              <span class="text-primary glyphicon glyphicon-star form-control-feedback"></span>
            </div>
            <div class="form-group has-feedback">
              <input type="password" class="form-control" placeholder="密码确认" autocomplete="off">
              <span class="text-primary glyphicon glyphicon-star form-control-feedback"></span>
            </div>
            <div class="form-group">
              <input type="text" class="form-control" placeholder="游戏帐户" autocomplete="off">
            </div>
          </div>
        </div>
        <div class="col-xs-12 col-md-6">
          <div class="reg-panel">
            <h3>联系方式</h3>
            <div class="form-group">
              <input type="text" class="form-control" placeholder="称呼" autocomplete="off">
            </div>
            <div class="form-group has-feedback">
              <input type="text" class="form-control" placeholder="手机号码" autocomplete="off">
              <span class="text-primary glyphicon glyphicon-star form-control-feedback"></span>
            </div>
            <div class="form-group has-feedback">
              <input type="text" class="form-control" placeholder="E-Mail" autocomplete="off">
              <span class="text-primary glyphicon glyphicon-star form-control-feedback"></span>
            </div>
            <div class="form-group has-feedback">
              <input type="text" class="form-control" placeholder="IM号码(QQ & Skype)" autocomplete="off">
              <span class="text-primary glyphicon glyphicon-star form-control-feedback"></span>
            </div>
          </div>
        </div>
        <div class="col-xs-12 col-md-6">
          <div class="reg-panel">
            <h3>支付详情</h3>
            <div class="form-group has-feedback">
              <input type="text" class="form-control" placeholder="银行名称" autocomplete="off">
              <span class="text-primary glyphicon glyphicon-star form-control-feedback"></span>
            </div>
            <div class="form-group has-feedback">
              <input type="password" class="form-control" placeholder="银行户名" autocomplete="off">
              <span class="text-primary glyphicon glyphicon-star form-control-feedback"></span>
            </div>
            <div class="form-group has-feedback">
              <input type="password" class="form-control" placeholder="银行账号" autocomplete="off">
              <span class="text-primary glyphicon glyphicon-star form-control-feedback"></span>
            </div>
            <div class="form-group has-feedback">
              <input type="text" class="form-control" placeholder="银行支行" autocomplete="off">
              <span class="text-primary glyphicon glyphicon-star form-control-feedback"></span>
            </div>
          </div>
        </div>
        <div class="col-xs-12 col-md-6">
          <div class="reg-panel">
            <h3>市场信息</h3>
            <div class="form-group">
              <input type="text" class="form-control" placeholder="推广网站" autocomplete="off">
            </div>
            <div class="form-group">
              <input type="text" class="form-control" placeholder="网站流量" autocomplete="off">
            </div>
          </div>
        </div>
        <div class="col-xs-12">
          <a href="#" class="btn btn-lg btn-primary visible-xs-block visible-sm-block visible-md-inline-block visible-lg-inline-block">申请</a>
        </div>
      </div>
    </form>
  </div>
</div>